DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Hyponatremia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old hypertensive and diabetic, who was hospitalized after syncope and fall. He stated that he was dizzy and felt that his blood sugar was probably low. He sustained a scalp laceration. Carotid Dopplers revealed less than 50% stenosis. Chest x-ray was negative. MRI of the brain in the remote past revealed prominence of the cisterna magna on both sides. Pituitary was atrophic, having the appearance of empty sella back then. Head CT following this recent fall was done, which revealed no bleed or fracture, just soft tissue injury.
In the last month or so, his glyburide was increased. He has been on Trileptal for about 6 years for seizures. He has a glass of alcohol a couple of times a month. For many years, he had 3 rum and cokes each evening but has not done this for some time. While he was on Avandia, he has not had any swelling. Additionally, he was on lisinopril. He denies any edema. He feels he empties his bladder fully. Sometimes, he gets up at night to void. His blood sugars have been well.
PAST MEDICAL HISTORY: Hypertension and diabetes.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
HABITS: As above regarding alcohol. He does not smoke.
OUTPATIENT MEDICATIONS: Trileptal 600 mg 2 tablets b.i.d., glyburide 2.5 mg t.i.d., metformin 500 mg t.i.d., Lipitor 40 mg daily, Avandia 8 mg daily, lisinopril 10 mg daily, and low-dose Bayer Aspirin 81 mg daily.
SOCIAL HISTORY: Married.
FAMILY HISTORY: Denies family history of kidney disease, nephrolithiasis or electrolyte disorders.
REVIEW OF SYSTEMS: Denies pain, nausea, lightheadedness or thyroid problems. He has been eating well. He is frustrated regarding his diet. He denies cough, shortness of breath, chest pain, back pain, kidney problems, problems emptying his bladder, prostate problems, edema or rash.
PHYSICAL EXAMINATION:
VITAL SIGNS: Afebrile. Blood pressure 118/74, blood pressure last night on chart was 178/96. Today, pulse is 74, respirations 22, weight 110 pounds and stable. Output on first shift was charted as 1250 with 90 in.
GENERAL: Alert, appropriate, and talkative.
HEENT: Anicteric. The patient does have ecchymosis around his eyes and forehead.
NECK: Without JVD or adenopathy.
CHEST: Clear.
BACK: Without CVA tenderness.
HEART: Regular rate and rhythm without gallop or rub.
ABDOMEN: Soft.
EXTREMITIES: Without edema.
LABORATORY DATA: Urine osmolality is still pending. Spot urine sodium 64. TSH was within normal limits. Glucose 114, BUN 14, creatinine 0.8, sodium 123, potassium 5.1, chloride 89, bicarbonate 27, and anion gap 9. Calcium, phosphorus, and albumin within normal limits. Serum osmolality 258, a.m. cortisol 22.2, within normal limits.
IMPRESSION:
1. Hyponatremia.
2. Hyperkalemia.
3. Diabetes.
4. Hypertension.
5. Recent fall.
6. Obstructive sleep apnea.
PLAN: Unfortunately, the patient’s urine osmolality has not yet been done. His a.m. cortisol and TSH are within normal limits. I suspect either SIADH or polydipsia. He is euvolemic and the urine osmolality will help us sort out what is going on. For now, we will start with fluid restriction. I will defer to the attending but would consider stopping glyburide and managing diabetes with an alternative agent as this may cause hyponatremia. Trileptal may be contributing also, though he has been on that for a number of years. The glyburide dose was recently increased. Will defer to primary physician on this. The patient does have a history of significant alcohol use. Questionable underlying liver disease. Consider repeating the CT scan in light of his recent fall. He is also on ACE inhibitor, which could be contributing, but I think it is less likely. Will check the urinalysis, renal ultrasound and renal artery Doppler. Potentially, if he has difficulty with urinary retention, this may explain why he may have elevated potassium. In this diabetic, there is a potential for some underlying hyporeninemic hypoaldosteronism. I would also recommend checking orthostatics and following up blood pressures. Will defer diabetes management to primary service, as well as management of his recent fall. I recommend following up his blood pressures. I recommend the patient continue CPAP for his obstructive sleep apnea.
Thank you very much for this consultation. We will follow the patient with you.
